Partnering to Grow New Perioperative Nurses

By Lisa Alikhan, Competency & Credentialing Institute

The history of the Nurse in Surgery Essentials (NISE) Certificate, developed in an effort to respond to a persistent shortage of perioperative nurses, offers valuable insights for organizations trying to address staffing and/or skills shortages in critical positions.  


There are multiple factors that contribute to a persistent shortage of perioperative nurses in the United States. Chief among these are many who plan to retire or transition away from employment in the operating room (OR) within the next 10 years plus the lack of new nurses entering the specialty. A commonly cited reason for high incidents of turnover in perioperative environments is a lack of sufficient training and quality orientation to the fundamentals of perioperative nursing; this despite a mountain of publicly available literature linking the quality of staff training to increased job satisfaction and subsequent retention.

Historically, perioperative nursing experiences have been excluded from most United States nursing education programs.[i],[ii] This lack of exposure is concerning because in 2014, 55.8% of perioperative nurse leaders reported having difficulty recruiting staff members and 67.9% reported that they expected to encounter recruitment problems in the next five years.iii This shortage may affect patient safety and access to surgical care. In addition, hospitals and surgical centers may lose revenue if adequate staffing is unavailable.[iv] These statistics are problematic since surgical procedures account for one third or more of a hospital or a medical facility’s revenue.

To address these concerns, and to prepare for an increased demand in surgical procedures driven by an aging population, healthcare systems have resorted to “growing and training” their own OR nurses. This has led to the establishment of perioperative nurse residency programs and other innovative partnerships. These programs have been successful, but there are not enough of them. The need exists too, for more training to assess critical thinking and the practical application of skills necessary for entry to practice. Ideally, the skills assessed would align with the competencies identified in the role delineation study for the Certified Perioperative Nurse (CNOR) certification exam, which is administered by the Competency & Credentialing Institute (CCI). Nurses are eligible to take the exam after working in the OR for two years and acquiring 2,400 hours of experience.

The Case

In 2017, CCI partnered with the National Institute for First Assisting (NIFA) to create a certificate program designed to introduce nurses to the practice of perioperative nursing. The Nurse in Surgery Essentials (NISE) Certificate differs from others, in that its content was developed based on findings from the CNOR credential job analysis. The course introduces concepts from each of the nine domains covered on the certification exam. A variety of competency assessment tools are used to assess participants throughout the course, and participants are assessed based on application of knowledge and how well they are able to perform certain tasks.

The program was developed by the CCI Director of Education, Dawn Whiteside, MSN, RN, CNOR, RN-BC, RNFA, and the NIFA Director of Education, Kimberly Jones, MSN-Ed., RN, CNOR, RNFA, who also serves as the course administrator. When asked how the program was received, she shared that she spent a lot of time in the beginning explaining the benefits of building a training program that doesn’t rely solely on traditional exam based methodology. In particular, some preceptors were skeptical about the use of the Behaviorally Anchored Rating Scales (BARS) method. This method evaluates on the job performance against preset criteria and specific sets of behavior that are anchored to performance standards. Individuals are assessed on how they actually respond to or perform under specific circumstances (e.g.audibly counting items concurrently with the scrub person to prevent retention of surgical items), vs. what skills and experience they have.

The NISE certificate program uses a dual review process and participants are rated by both their preceptor and the NISE course administrator. Kim explained that OR management is under pressure sometimes to train nurses rapidly, and that shortcuts might be taken. Supervisors may be tempted to sign off on a new nurse’s ability to perform a procedure at standard, even when performance does not meet guidelines. The dual review process ensures two people validate a nurse’s readiness to advance further in the program, but some felt this decision should be determined by facility personnel only. As co-developer of the certificate, Kim was able to explain that the performance criteria to progress is rooted in the CNOR job analysis validation study.

“People are used to consuming content linked to an assessment, so I have to explain how this course is different. There were times when I wondered if we had been too ambitious with our development and experimentation, but in time the frustrated calls and emails subsided and we began to receive a lot of positive feedback,” Jones said.

The NISE Certificate program is designed to be completed in eight months and incorporates the following methods to assess competency:

  • Competency Assessment Forms: Forms are included with each unit or module, and course participants must receive a satisfactory rating from their preceptors or direct supervisors while performing 16 tasks.
  • Low-Stakes Traditional Assessments: Course participants complete online chapter quizzes, unit tests, and must obtain a passing score on the final assessment. Items were developed based on domains that appear in the CNOR exam blueprint. Though written for a novice in the OR, the items are intended to assess critical thinking skills.
  • Reflective Journaling: Course participants are required to describe how they have incorporated new knowledge, skills and techniques to inform or impact their practice. The exercises must be submitted to the course administrator for review. Feedback is given to guide changes in practice as needed.
  • BARS Rating: Course participants are rated by a preceptor or supervisor against predefined criteria. A quantitative and qualitative appraisal is performed and a rating of Novice or Advanced Beginner is assigned. A video of the exercise completed is uploaded to the course administrator to complete a secondary review.

Participants who obtain a satisfactory rating for each course requirement are issued a Certificate of Mastery, while those who complete the course but do not achieve a satisfactory rating in every course receive a Certificate of Completion.

In Q1 of 2019, the NISE certificate program received initial accreditation from the Accreditation Board for Specialty Nursing Certification (ABSNC). ABSNC accredits more than 65% of specialty nursing certification programs. NISE is the only perioperative nurse training program to be accredited by a national accreditation body, and was the second certificate program to be accredited. To achieve accreditation, the NIFA organization voluntarily submitted to a rigorous review of their internal operations and the development and administration of the certificate program.

As of the end of Q3, 2019, program sales for the NISE certificate program had increased by about 28% from the year prior. “I can’t say whether this was entirely due to achieving an accredited status, but being able to display the ABSNC seal of accreditation has been a really BIG DEAL for us,” Jones said. “Nurses in the field know ABSNC and I’ve had several questions and comments about it from those considering the program, so I believe there is a tangible link. We display the seal prominently and I feel like it shows that both NIFA and this program are on solid footing. When people ask me, what having an accredited training certificate program means, I tell them; I feel like it makes a difference.”

To ensure compliance with the standard for quality assurance, NISE collects course evaluations from all participants and preceptors. The information is compiled and reviewed on a quarterly schedule and adjustments are considered based on the results. The first two years of data consistently revealed two primary challenges.

1. Issue: Some preceptors and students resisted the multi-modal approach to validate knowledge and skills. This was perceived as a barrier to completion when compared to a single method.
Resolution: Messaging and FAQs were refined to provide the rationale for a variety of competency assessment methodologies and  describe the impact on practice.

2. Issue: Some dissatisfaction about the number of competency assessment forms nurses were required to complete. Nurses felt there were too many.
Resolution: Course review and revisions are in progress to reduce the number of assessments.

According to NIFA, the practice of continuous feedback has changed how the NISE course is positioned in the market and how their sales team talks to facilities about purchasing the course for their employees. NIFA seeks to educate prospective buyers about the benefits of a course that introduces the CNOR exam framework to nurses early in their development, and about the benefit to nurses (and ultimately patients) who earn a certificate from their accredited program.


CCI recognized that organizational partnerships outside of the traditional hospital and university relationship are critical to workforce planning efforts so the number of well- trained perioperative nurses could be increased. Additionally, they realized that partnering to assist others with program development related to the OR is a way to build a pipeline for their certifications. The partnership between CCI and NIFA resulted in the creation of a successfully accredited Assessment based Certificate Program to provide nurses with foundational knowledge needed to practice in the OR. The NISE program is in its third year of operations. 


[i] Young R, Takahashi J, Cheney A. Project alpha goes into action. AORN J. 1981;34(5):920‐939.

[ii] McNamara SA. Perioperative nursing in nursing school curricula. AORN J. 2006;83(2):301‐304.

[iii] Sherman, RO. Why we should be concerned about a shortage of perioperative nurses. Published October 25, 2012. Accessed 1/02/2020

[iv] Schmidt NA, Brown JM, Holmes L. Student perceptions about the influence of a perioperative nursing elective on career preferences. Int J Nurs Educ Scholarsh. 2016;13(1):55‐62.

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